Pharmacy personal care account

ABSTRACT

A method for providing insurance coverage to a subscriber comprises offering an insurance policy to the subscriber wherein the insurance policy comprises providing allowances to pay for one or more expenses covered by the insurance policy and providing monetary credits to the subscriber for any unused portion of a given allowance where the monetary credits can be used to cover the cost of a subsequent allowed expense. The insurance policy may be a pharmacy benefits plan. The covered expenses may be pharmacy expenses. The allowed expenses may be medical expenses which qualify under Section 213 of the US Internal Revenue Code for payment by an employer without the subscriber having to declare the payment as taxable income.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.13/028,879, filed Feb. 16, 2011, entitled “Pharmacy Personal CareAccount,” now U.S. Pat. No. 8,126,737, issued Feb. 28, 2012 which is acontinuation of U.S. patent application Ser. No. 11/197,200, filed Aug.4, 2005, entitled “Pharmacy Personal Care Account,” now U.S. Pat. No.7,895,054, issued Feb. 22, 2011, the contents of which are incorporatedherein by reference.

U.S. patent application Ser. No. 11/197,200 is a continuation-in-part ofU.S. patent application Ser. No. 11/119,125, filed Apr. 29, 2005,entitled “Pharmacy Benefits Design” and a non-provisional of U.S.Provisional Patent Application Ser. No. 60/601,918, filed Aug. 16, 2004,the contents of which are incorporated herein by reference.

U.S. patent application Ser. No. 11/119,125 is a non-provisionalapplication entitled “Pharmacy Benefits Design”, in turn, claims thebenefit of the filing date of U.S. Provisional Patent Application Ser.No. 60/568,517, filed May 6, 2004; U.S. Provisional Patent ApplicationSer. No. 60/572,586, filed May 19, 2004; and U.S. Provisional PatentApplication Ser. No. 60/601,918, filed Aug. 16, 2004; entitled “PharmacyBenefits Design,” the contents of which are incorporated herein byreference.

FIELD OF THE INVENTION

The invention is in the field of insurance.

BACKGROUND

There is a long felt need in the health care industry to provide anemployer sponsored health insurance policy that simultaneously coversthe majority of an employee's health care costs while at the same timeencourages cost savings behavior by the employee.

Co-pending US patent application “Pharmacy Benefits Design”, U.S.application Ser. No. 11/119,125 filed Apr. 29, 2005, for example,describes a system and method for providing health insurance to anemployee (i.e., an “insured” or a “subscriber”) wherein the healthinsurance comprises a pharmacy benefits plan and wherein the pharmacybenefits plan provides a monetary allowance for each prescription ofdrugs that the insured purchases. If the insured purchases a drug, theinsured only has to pay for the cost of the drug that is in excess ofthe allowance up to a per script maximum. The plan is referred to hereinas an RxImpact plan.

All drugs within an RxImpact plan are categorized into one of four orfive Groups. The Groups are A, B, C, D and optionally E. All drugswithin the same group have the same allowance per prescription.

Each group contains all drugs that have a similar effect on anticipatedfuture medical costs that an insured would face if they did not take thedrugs in a timely manner. Drugs are assigned to Group A, for example, ifit is anticipated that not taking them would result in significantfuture medical costs for an insured within one year. Antibiotics, forexample, would be categorized as Group A drugs. If an insured did nottake an antibiotic when prescribed, then it is anticipated that theinsured would likely require future medical treatment, such as anemergency room visit or a hospitalization.

Group B drugs might comprise those that would result in significantmedical costs which are incurred in a time frame that exceeds one year.Anti-cholesterol drugs are an example of Group B drugs. If an individualfails to take his/her anti-cholesterol medication in the short term,that individual may have a heart attack requiring hospitalization sometime in the future.

Group C drugs might comprise those that would not result in futuremedical costs if not taken, but might result in increased employeeproductivity. Non-sedating antihistamines are examples of Group C drugs.

Group D drugs might comprise those that would not result in eithersubsequent health care costs or reduced employee productivity if nottaken, but might improve an insured's lifestyle. Hair restoration drugsare examples of Group D drugs.

Optional Group E drugs might comprise those that do not fall into one ofthe above four Groups. Anesthesia drugs are examples of Group E drugs.

Under an RxImpact pharmacy benefits plan, both generic and brand namedrugs that are prescribed for the same indication would be assigned tothe same Group. Lipitor (brand name) and Lovastatin (generic) are bothprescribed for the treatment of high cholesterol and would therefore, beassigned to the same Group, Group B. They would also, therefore, havethe same allowance.

Furthermore, drugs prescribed for different indications might also beassigned to the same Group provided they had similar impact onsubsequent medical costs. Antibiotics and diabetes drugs, for example,are prescribed for very different indications. Antibiotics areprescribed to treat infections. Diabetes drugs are prescribed to controlblood sugar. Yet both antibiotics and diabetes drugs would be assignedto Group A since it is anticipated that not taking either of them wouldresult in subsequent higher medical costs, such as an emergency roomvisit, within a year.

Different Groups of drugs in an RxImpact plan might have differentallowances per prescription. Group A drugs, for example, might get anallowance of $30 for each prescription. Group B drugs might have anallowance of $20 per prescription. Group C drugs might have an allowanceof $10 per prescription. Groups D and E might not have an allowance.

Group D drugs might not have an allowance since an employer offering anRxImpact plan to their employees might not wish to provide health carecoverage for drugs that are primarily prescribed to enhance a person'slifestyle but do not result in the reduction of subsequent health carecosts or increased employee productivity.

Group E drugs might not have an allowance since they are not covered bythe RxImpact Plan.

Often times the cost of a given prescription is less than the allowancefor the prescription. It has been discovered that the concept of anRxImpact plan would be more acceptable to employees and employees mightbe more savvy shoppers if a means could be provided whereby theemployees could accumulate monetary credits for any unused portion of agiven allowance provided for a given pharmaceutical purchase. AnRxImpact plan would also be more acceptable if the monetary creditscould be accumulated by employees without the employees having todeclare the monetary credits as taxable income. An RxImpact plan wouldalso be more acceptable if a convenient means could be provided toinform employees of the accumulation of their monetary credits. AnRxImpact plan would also be more acceptable if a convenient means couldbe provided for employees to redeem their monetary credits for otherhealth care costs beyond merely pharmaceutical costs.

SUMMARY OF THE INVENTION

The Summary of the Invention is provided as a guide to understanding theinvention. It does not necessarily describe the most generic embodimentof the invention or all species of the invention disclosed herein.

The present invention is a method and apparatus for providing insurancecoverage to a subscriber. The method comprises offering an insurancepolicy to the subscriber. The insurance policy provides allowances topay for certain covered expenses. If the actual cost of a coveredexpense is less than the allowance for that expense, then a monetarycredit is applied to a personal care account for the subscriber. Thesubscriber may then use the monetary credit to offset or pay for thesubscriber's cost share (e.g., deductible, copay) for certain otherproducts or services covered under the policy. These other products orservices are referred to herein as “allowed expenses”. The allowedexpenses may or may not be the same as the covered expenses.

The method further comprises the insurance company accepting payment ofa premium so that the insurance coverage will be in force. The premiummay be paid in part by the subscriber and in part by another entity,such as the employer of the subscriber.

Alternatively, an employer may serve as the insurance company in thesense that the employer directly pays the benefits of the insurancecoverage. This is known as a “self funded” insurance program. Theemployer then, in essence, pays premiums to itself. The premiums beingequal to the cost of providing the benefits.

An employer that serves as an insurance company many, in turn, may hirea licensed insurance company, such as Humana Inc. of Louisville Ky., toadminister their insurance coverage. The employer would then pay thelicensed insurance company an administration fee.

The offering of a policy and the acceptance of a premium may be carriedout at least in part by one or more information systems. For example,the policy may be offered via the Internet. Acceptance of the premiummay be by acceptance of an electronic funds transfer.

The insurance policy may be a health insurance policy comprising apharmacy benefits program. The invention, however, is not limited tohealth insurance policies or pharmacy benefits programs.

An example of a suitable pharmacy benefits program is an RxImpact plan.

The present invention is useful for increasing the acceptance amongpotential subscribers of a pharmacy benefits program wherein a singleallowance is provided for each purchase of a prescription drug, the drugbelonging to a given set of drugs. A given set of drugs, for example,may be those drugs that provide for a reduction of subsequent healthcare costs within a year. Each drug within the given set of drugs wouldhave the same allowance irrespective of whether or not the drug was ageneric or brand name drug.

The present invention is further useful in encouraging subscribers torequest low cost but nonetheless effective pharmaceutical alternativesto treat a given indication. This lowers the overall cost of providingthe pharmaceutical benefits program.

The present invention may comprise a debit card. The debit card is usedby a subscriber to pay for allowed expenses using the credits fromcovered expenses.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram of the flow of information that occurs when asubscriber purchases a covered expense.

FIG. 2 is a diagram of the flow of information that occurs when asubscriber purchases an allowed expense.

FIG. 3 shows two graphs illustrating how funds are credited to atraditional HRA account, an HRA account that has been modified to serveas a personal care account (i.e. PCX account).

DETAILED DESCRIPTION

The following detailed description discloses various embodiments andfeatures of the invention. These embodiments and features are meant tobe exemplary and not limiting.

DEFINITIONS

The definitions provided below are to be applied to their respectiveterms or phrases as used herein unless the context of a given particularuse of a given term or phrase clearly indicates otherwise.

The terms “health insurance”, “health care plan”, or “benefit plan”refer to an insurance plan that pays benefits to an insured in the eventthat the insured incurs covered medical costs.

The term “pharmacy benefits plan” or the like refers to an insuranceplan that provides benefits to an insured for certain prescription andother drug costs. A pharmacy benefits plan may be a subset of a givenhealth insurance plan. A pharmacy benefits plan may also be astand-alone insurance policy.

The term “plan year” refers to an annual period for which a given healthcare plan is in force.

The term “open enrollment period” refers to a period of time that aprospective insured can select their health care plan for an upcomingplan year.

The term “insured” or “subscriber” refers to one or more persons whopurchase and/or are covered by an insurance policy, such as a healthinsurance policy. A subscriber may be an employee of an employer whoprovides medical insurance to their employees. A subscriber may also bea dependent, spouse, partner, or other family member of the employee.

The term “prospective insured” refers to a person who is consideringenrolling in a given insurance plan.

The term “benefit” or the like refers to money or other considerationprovided by an insurance company to an insured as compensation for acovered event.

The phrase “out-of-pocket costs”, the abbreviation “OOP”, or the likerefer to the portion of an insurance claim that an insured must paydirectly.

The term “Health Plan Wizard” refers to one or more web pages or thelike that a prospective insured would use to enroll in a given healthinsurance plan.

The term “cost” refers to the sale price of a particular item inquestion, such as a pharmacy script.

The terms “script”, “prescription”, “pharmacy script” and the like referto an order for a given quantity of a given drug.

The term “information system” or the like refers to one or more ofcomputers, servers, input devices, output devices, data storage devices,telecommunications equipment and software. Information systems maycommunicate with other information systems via telecommunications means,such as the Internet. Information systems may also communicate withpersons via input/output devices. Persons may communicate with otherpersons using information systems.

Monetary quantities disclosed herein are in US dollars as of August2005. The quantities may be converted to other currencies at other timesusing published exchange rates and appropriate inflation factors.

The terms “Group”, “level” or “tier” refer to a category assigned to agiven script under a given pharmacy benefits plan. The category is usedto determine the coverage of a given script under the given pharmacybenefits plan. “Groups” are generally used with respect an RxImpact planor other plan based on allowances for a given script. “Level” or “tier”are generally used with respect to a copay plan.

The phrase “covered expense” refers to an expense that is reimbursableat least in part by an insurance policy. A covered expense may be a goodor service.

The phrase “allowed expense” refers to an expense that is payable from apersonal care account or the like under the terms of an insurancepolicy. An allowed expense may be a good or service.

The phrase “personal care account” or “PCX” refers to an account that ismaintained on behalf of a subscriber which contains monetary creditswhich can be used by the subscriber to pay for allowed expenses.

A personal care account may also be a Health Reimbursement Arrangementas defined by Section 105 of the United States Internal Revenue Code asof June 2004. Section 105 is incorporated herein by reference.

A “monetary credit” is a credit that is denominated in currency or onethat can be converted to a denomination of currency.

Information Flow when Purchasing a Covered Expense

FIG. 1 illustrates the flow of information of the present invention whena subscriber purchases a covered expense. The figure shows subscriber100, insurance company 102, claims manager 104, and covered vendor 106.The subscriber has personal ID card 108.

The subscriber and covered vendor are shown as stick figures.

The insurance company and claims manager are shown as rectangles withrecurved corners.

The insurance company comprises an information system 142 and employees(not shown). The information system comprises computers, software,input/output devices and communications devices.

The claims manager comprises an information system 144 and employees(not shown). The information system comprises computers, software,input/output devices and communications devices.

Information that is transferred in real time is shown as solid headarrows (e.g., arrow 122). Real time information transfer implies thatthe information is transferred during a particular transaction andgenerally occurs on a time scale of minutes, seconds or less.

Information that is transferred in batches (e.g., arrow 110) is shown asopen head, dashed arrows. Batch information transfer implies thatcomparable information for a plurality of persons or entities istransferred at once. Batch information transfer is commonly done athourly, daily, monthly or yearly intervals. The interval chosen is thatwhich is appropriate to the needs of those sending or receiving theinformation.

All information transfers illustrated in FIGS. 1 and 2 may be by meansof the modulation of an electronic or optical carrier wave transferredand/or relayed between one information system and another. For example,the transfer 112 of policy holder information between insurance companyinformation system 142 and claims manager information system 144 may beover the Internet via information packets using a TCP/IP protocol. Theinformation packets cause the claims manager information system 144 tocarry out certain desired steps of the invention, such as recordingmonetary credits in a client limit savings field 158, thus producing aconcrete useful and tangible result.

The description of the insurance company, claims manager and otherentities as separate entities in FIGS. 1 and 2 is, in part, for theconvenience of explanation. Any number of entities illustrated in FIGS.1 and 2 as being separate entities may exist as a single entity or maybe subsets of each other. For example, claims manager 104 may be adepartment of insurance company 102.

Furthermore, entities illustrated as single entities may be aggregatesof multiple entities. For example, a portion of the information system142 of insurance company 102 may be under the control of an accountingfirm, such as MHM Resources of Kansas City Mo., that providesinformation processing services to the insurance company.

The particular illustration of entities shown in FIGS. 1 and 2, however,has a surprisingly low unit cost per subscriber of carrying out themethods of the invention. Each entity can carry out its functions formultiple and even competing customers or clients. For example, claimsmanager 104 can carry out its functions for multiple competing insurancecompanies (who have a license to the invention) using the sameinformation system 144. Thus the claims manager can take advantage ofeconomies of scale and lower the unit cost of providing the concretetangible results of the invention to multiple subscribers.

Initiating a Personal Care Account

Referring back to FIG. 1, a personal care account 152 is set up for asubscriber when the subscriber acquires an insurance policy offered byan insurance company 102.

The insurance policy provides for the payment of an allowance for agiven covered expense. If the cost of a given covered expense exceedsthe allowance, then the subscriber must pay the difference. A per scriptmaximum may be applied to provide additional financial protection forthe subscriber. An annual “out of pocket” maximum may be included toprovide the subscriber with additional financial protection. If the costof a given covered expense is less than the allowance, then thesubscriber is given a monetary credit for at least some of the unusedportion of the allowance. The credit may then be used to pay for certainallowed expenses. The allowed expenses may or may not be the same as thecovered expenses.

The credits may be accumulated in a personal care account assigned tothe subscriber.

After the subscriber acquires the insurance policy, election information110 is transferred to the insurance company from the subscriber. Theelection information comprises personal identification of the subscriberand identification of the particular policy that the subscriber haselected to purchase.

The election information may be transferred to the insurance company inwriting or via inputting the information into a web interface or otherelectronic means.

The insurance company then sets up a personal care account for thesubscriber within their information system.

The personal care account comprises an identifier of the subscriber 155,and the balance 157 of the account. The personal care account data for alarge number (e.g., more than 1000) of subscribers may be stored in anelectronic data warehouse.

The balance of the personal care account assigned to a given subscribermay be set to zero when the subscriber first purchases the insurancepolicy. If the subscriber has purchased a renewal of an existing policythat had provided a personal care account, then the balance of thepersonal care account may be set to the balance remaining from the priorplan year. This is referred to as a year-to-year carryover of benefits.

The insurance policy may be a health insurance policy offered by anemployer to its employees. The employees may only be allowed to purchasea policy during an “open enrollment period” or upon the occurrence of aqualifying “life event” (e.g., divorce, marriage, birth of child, etc.).The open enrollment period may last between one week and one month. Theopen enrollment period may be offered on an annual basis.

The health insurance policy may have a term of one year. The term may bereferred to as a “plan year”. The plan year may commence at some timeafter the conclusion of the open enrollment period.

At the end of an open enrollment period and prior to the commencement ofa plan year, the insurance company may transfer policyholder information112 regarding the subscriber to a claims manager 104. A claims manageris an entity that processes claims made by a subscriber against theirinsurance policy. A suitable claims manager for claims against thepharmacy benefits plan of a health insurance policy is Argus HealthSystems, Inc. of Kansas City, Mo.

The policyholder information may comprise personal identifiers of thesubscribers, and the identifiers of the insurance policies that thesubscribers have purchased. The policyholder information may beencrypted and otherwise secured such that the transfer meets thenecessary requirements for subscriber confidentiality, such as therequirements of HIPAA (US Health Insurance Portability andAccountability Act of 1996, incorporated herein by reference).

The policyholder information may also comprise pricing data fordifferent covered expenses. For example, if the covered vendor is apharmacist, the pricing data may comprise the prices for differentprescriptions that the insurance company has previously negotiated withthe pharmacist.

The information may be transferred in a mainframe data set over theInternet or by other suitable electronic means.

Subscriber ID Card

Once a subscriber has coverage under an insurance policy, they may beissued a personal ID card 108. The personal ID card may comprise thename of the subscriber and an identification number.

Different states within the United States may require certaininformation to be displayed on a personal ID card. Texas, for example,requires that the names of the dependents of a subscriber be displayedon a personal ID card if the insurance policy is a health insurancepolicy regulated by the Texas Insurance Commission.

Purchasing a Covered Expense

When a subscriber purchases a covered expense from a covered vendor 106,the subscriber provides coverage information 122 to the covered vendor.The coverage information may comprise a personal identifier for thesubscriber.

The subscriber may transfer the information verbally or by othersuitable means.

The covered vendor then transfers covered expense information 124 to theclaims manager. The covered expense information may comprise a personalidentifier of the subscriber and a product code for the covered expense.

The covered expense may be a prescription. The covered vendor may be apharmacy, such as CVS Corporation of Woonsocket, R.I.

The covered expense information may be transferred via a modemconnection or other electronic means.

After the claims manager receives the covered expense information, itsets up a covered expense record 154 in its information system 144. Thecovered expense record comprises data fields related to the coveredexpense purchase including a personal identifier 156 of the subscriberand a client limit savings field 158.

The client limit savings field is used to record any monetary creditthat the subscriber may be entitled to as a consequence of the purchaseof the covered expense. If the purchase price of the covered expense isless than the allowance for the covered expense, then the client limitsavings field is set to at least a portion of the difference. If thepurchase price of the covered expense is greater than or equal to theallowance then the client limit savings field is set to zero. Thepurchase price may include a sales tax on the purchase.

After the covered expense record is set up, the claims manager thenlooks up the actual allowance and price for the covered expense. Theallowance is determined from the terms of the insurance policy that thesubscriber purchased and the product code for the covered expense. Theterms of the policy that the subscriber purchased are determined usingthe personal identifier of the subscriber and a database of terms fordifferent policies. The database of terms for different policies may bepart of the information system of the claims manager.

The claims manager may then set the value of the client limit savingsfield equal to at least a portion of the positive difference between theallowance and purchase price. Otherwise, the value is set to zero.

The value of the client limit savings field may be set to a negativenumber in certain circumstances. For example, if the subscriber isreturning a covered expense from a previous purchase, then the clientlimit savings field would be set to the negative difference between theallowance and the price of the covered expense. This would cancel outthe positive monetary credit accumulated by the subscriber when he/sheoriginally purchased the covered expense.

The claims manager then transfers balance owed information 126 to thecovered vendor. The balance owed information comprises the positivedifference, if any, between the price of the covered expense and theallowance.

A prescription of Cephalexin, for example, might have a price of $36.89.The allowance for Cephalexin might be $40. The claims manager wouldrecord $3.11 in monetary credits in the client limit savings field. Theclaims manager would indicate to the covered vendor in the balance owedinformation that the balance owed was $0.

In another example, a prescription of Flonase might have a price of$44.85. The allowance for Flonase might be $20. The claims manager wouldnot record any monetary credits in the client limit savings field. Theclaims manager would indicate to the covered vendor in the balanced owedinformation that the balance owed is $24.85.

The balance owed information 126 may be transferred by modem or otherelectronic means.

After receiving the balance owed information, the covered vendor wouldthen convey final transaction information 128 to the subscriber. Thefinal transaction information might comprise the balance owed.

The final transaction information may be transmitted verbally or byother suitable means.

The subscriber and the covered vendor may then conclude the transactionof the purchase of the covered expense.

The covered vendor may be an automation, such as a vending machine, webpage or an automated telephone system. Coverage information 122 andfinal transaction information 128 may be transmitted over the Internetor a phone system.

The subscriber may have an agent act on their behalf. The agent may bean automation, such as a computer implemented ordering system.

The subscriber may be a corporate entity, such as a health maintenanceorganization.

Updating the Personal Care Account

The personal care account 152 maintained by the insurance company may beupdated by the claims manager on a periodic basis. The claims managertransmits accumulation amount information 132 to the insurance companyon a periodic basis. The information may be transferred quarterly (i.e.,every three months), monthly or more frequently. The information may betransferred in a flat file.

The accumulation amount information comprises a personal identifier ofthe subscriber and the sum of the monetary credits recorded in theclient limit savings fields 158 contained in the covered expense records154 associated with the subscriber. The covered expense records arethose that have been created since the prior transfer of accumulationamount information. The insurance company adds the monetary credits tothe balance 157 in the personal care account 152 of the subscriber.

Monetary credits can be thought of as special purpose, private issuemoney. Thus the known systems and methods for securely electronicallytransmitting government issued money can be used for transmittingmonetary credits.

The accumulation amount information may be entered into the informationsystem of the insurance company by persons typing the information into aworkstation. The information may also be entered by direct filetransfer.

The insurance company then transmits personal care account updateinformation 134 to the subscriber. Personal care account updateinformation may comprise the current balance in the subscriber'spersonal care account along with any changes and an indication of areason for each change.

The personal care account update information may be transmitted viaemail. It may also be available on a personalized web site accessible toa given subscriber. The information may also be available via anautomated phone system. The information may also be printed on paper andmailed.

The above described information transfers of election information 110,policy holder information 112, accumulation amount information 132, andaccount information 134 may be done in a batch mode for a large numberof subscribers. Thus the cost of transferring, processing and storingthe information can be kept low on a per subscriber basis.

Information Flow when Purchasing an Allowed Expense

FIG. 2 illustrates the flow of information of an exemplary embodiment ofthe present invention when a subscriber purchases an allowed expense.The figure shows subscriber 200, insurance company 202, debit cardprocessor 204, allowed vendor 206, employer 207, employer bank 208 andvendor bank 209. The subscriber is an employee of the employer. Thesubscriber may have a debit card 201.

The subscriber and allowed vendor are shown as stick figures.Subscribers may comprise information systems, such as personalcomputers, with access to the Internet. Vendors may also compriseinformation systems, such as credit card processing terminals.

The other entities are shown as rectangles with recurved corners.

The debit card processor, insurance company, employer, employer bank andvendor bank comprise information systems 242, 244, 247, 248 and 249respectively. They may also comprise their respective employees (notshown).

The information systems may comprise computers, software andcommunication devices.

Exemplary Embodiment

In the exemplary embodiment illustrated in FIG. 2, a personal careaccount 256 (PCX) for a subscriber is set up and administered as amodified version of a traditional “Health Reimbursement Arrangement” asdefined in Internal Revenue Bulletin, No. 2002-28, Jul. 15, 2002,published by the US Internal Revenue Service. The Bulletin isincorporated herein by reference.

Other traditional tax-advantaged accounts, as allowed by US law orcomparable laws in other jurisdictions, may also be modified to serve aspersonal care accounts. These other traditional tax-advantaged accountsinclude Health Savings Accounts and Flexible Spending Accounts.

Traditional HRA

In a traditional Health Reimbursement Arrangement, an employer offershealth care benefits to an employee. The health care benefits areadministered by an insurance company. As part of the health carebenefits, the employer instructs the insurance company to set up atraditional HRA account 254 on behalf of an employee and provides aninitial credit in the account. The credit is to be used to help pay forthe employee's health expenses. The initial credit is referred to as anelection amount.

During the course of a given plan year, the employee may purchasecertain health related goods and services from an allowed vendor. Ifthere is enough credit in the employee's HRA account, the insurancecompany will instruct the employer to pay the vendor directly for thegoods and services. The employee never touches the money. The insurancecompany then records the cost of the goods and services as a debit tothe employee's HRA account.

Because the employer pays the vendor directly and because the goods andservices are allowable health care expenses as specified in section 213of the US Internal Revenue Code (incorporated herein by reference), thefunds used to pay for the allowable expenses are not treated as grossincome to the employee and therefore are not taxed by the US federalgovernment as gross income to the employee. Other restrictions apply.Hence the employee can receive more health care goods and services for agiven election amount than if the election amount was provided directlyby the employer to the employee as gross income.

Traditional HRA accounts allow for the rollover of unused funds from oneyear to the next. Hence if an employee does not use the entire electionamount in a given year, the balance can be carried over to the next yearand added to the employee's election amount for the subsequent year.

Traditional HRA accounts for large numbers of employees are administeredby computer systems running traditional HRA account management software,such as Winflexone® provided by MHM Resources Inc., of Kansas City,Kans.

It has been discovered that if the computer systems and softwareadministering traditional HRA accounts are modified such that electionamounts of HRA accounts can be updated on a more frequent basis thanannually, then the systems can be used to administer the personal careaccounts of the present invention while at the same time avoidingadverse tax consequences for employees. This is a surprisingly low costmeans of implementing and administering personal care accounts.

Personal Care Accounts Administered as Modified HRA Accounts

FIG. 3 illustrates how traditional HRA accounts can be modified to serveas personal care accounts.

Referring to FIG. 3, graph 301 illustrates how an election amount 310for a traditional HRA account is set at the beginning, Y0, of a givenplan year. Account balance is shown vertically. Time is shownhorizontally. Additions to an account are shown as vertical arrows.

If the initial election amount for a particular employee is zero (and ifthere is no carryover from the prior year), then no HRA account is setup for that employee.

If there are no charges against the HRA account in the given plan year,then the account balance of the initial election amount 310 carries overinto the next plan year Y1, and the next year's initial election amount311 is added to the account.

Referring to graph 302, in order to implement a PCX account, thetraditional HRA administration software and databases are modified suchthat:

All subscribers who elect to have insurance plans providing accumulationof credits for unused portions of a given allowance for a pharmacypurchase are assigned a PCX account, even if the initial election amountis zero;

Initial election amounts 330 of PCX accounts may be zero without causingthe account to be deleted;

Accumulated credits 331, 332, 333, 334, from given time periods (e.g.,Q1) are treated as election amounts for the next given time period(e.g., Q2)

Any balance of a PCX account unused as of the end of a given period oftime is treated as a carryover to the next period of time.

Preferably, the frequency of credit updates to a PCX account is chosensuch that the subscriber will perceive a direct feedback between theirpharmacy choices and the accumulation of credits to be applied towardsthe purchase of allowed health care expenses. The longest the periodshould be is quarterly (i.e. every three months). If periods are longer,subscribers will be less likely to appreciate the impact of theirdecisions and the effectiveness of providing monetary credits toencourage cost saving behavior in subscribers will be reduced.

Shorter update periods such as monthly, weekly, daily or even real timeare preferred unless they are so frequent that subscribers rarely seeany credit to their PCX accounts. Subscribers might then ignore thecredits and again, the effectiveness of providing monetary credits toencourage cost saving behavior in subscribers will be reduced.

Preferably, update frequency should be chosen such that subscribers seecredits of a few dollars to a few hundred dollars on a regular basis.Update periods between weekly and quarterly will accomplish this.

Initiating a Personal Care Account

Referring back to FIG. 2 unless otherwise indicated, a personal careaccount 256 is set up for a subscriber as a modified traditional HRAaccount when the subscriber acquires an insurance policy offered by aninsurance company 202. At that time, election information 210 istransferred to the insurance company from the subscriber. The insurancecompany then sets up a personal care account 256 (PCX) for thesubscriber within their information system.

As used herein, insurance company 202 may also be a third partyadministrator, such as SHPS of Louisville Ky. A third partyadministrator is an entity that administers one or more traditional HRA,FSA or HSA accounts on behalf of the subscribers of one or more healthinsurance companies or other entities.

The balance of a personal care account may be set to zero when asubscriber first purchases the insurance policy. If the subscriber haspurchased a renewal of an existing policy, then the balance of thepersonal care account may be set to the balance of the personal careaccount remaining from the prior plan year.

The insurance policy may be a health insurance policy offered by anemployer to its employees. The employees may be allowed to purchase apolicy during an open enrollment period. They also may be allowed topurchase a policy if they experience a qualifying life event, such asjoining the company in the middle of a plan year.

At the end of an open enrollment period and prior to the commencement ofa plan year, the insurance company may transfer subscriber information212 regarding all of the subscribers in a given employer group to adebit card processor 204. A suitable debit card processor for thepharmacy benefits plan of a health insurance policy is Metavante ofMilwaukee, Wis.

The subscriber information may comprise personal identifiers of thesubscribers, and the balance of the subscribers' respective personalcare accounts 256.

Subscriber information may also contain identifier codes of allowedvendors.

The information may be transferred in a flat file over the Internet orby other suitable electronic means.

The debit card processor then sets up stand-in personal care accounts257 (sPCX) for the subscribers within its own information system 244.

The insurance company may also transmit personal care account updateinformation 214 to the debit card processor from time to time. Personalcare account update information may comprise personal identifiers ofsubscribers and additional monetary credits (e.g., items 331, 332, 333,334 of FIG. 3) to the subscribers' respective personal care accounts.The monetary credits may have been received (132 FIG. 1) by theinsurance company (102 FIG. 1, 202 FIG. 2) from a claims manager (104,FIG. 1).

The debit card processor will then update their sPCX accounts 257.

There may be negative adjustments to a given sPCX account 257, such asif a subscriber leaves the employ of their employer 207. In that case,the sPCX account may be closed out and the subscriber's monetary creditswill be forfeited.

Other Spending Accounts

The subscriber information 212 or the personal care account updateinformation 214 may further comprise balance and update informationregarding other types of spending accounts that may be assigned to eachsubscriber.

Certain subscribers, for example, may each have a flexible spendingaccount 252. In the United States as of Jun. 1, 2004, flexible spendingaccounts are governed by Section 213(a) of the Internal Revenue Code,which is incorporated herein by reference. This Section allowssubscribers to contribute a certain fraction of their income to flexiblespending accounts on a pretax basis. The contributions to a flexiblespending account can be used to purchase certain 213(a) allowableexpenses, such as health care costs. Contributions to flexible spendingaccounts must be used for 213(a) allowable expenses in a given tax yearor within two and one half months thereafter, or they will be forfeited.

“Allowed expenses” as used herein may be a subset of the 213(a)allowable expenses, such as health care costs, as defined by Section213(a) of the Internal Revenue Code or other comparable regulations inforce at different times or in different jurisdictions.

One or more subscribers may also have traditional HRA accounts 254assigned to them. The conventional HRA accounts would be set up at thebeginning of a plan year with a given election amount as describedabove.

The debit card processor will set up and update stand-in spendingaccounts 253, 255, 257 assigned to each subscriber for the flexiblespending accounts, traditional HRA accounts, personal care accounts, andother accounts indicated by the insurance company. The balances of theseaccounts will be used to pay for allowed expenses.

In the event that a subscriber makes a purchase of an allowed expense,certain spending accounts assigned to the subscriber may be debitedbefore other accounts. For example, a flexible spending account may bedebited before a personal care account due to the fact that the balancein a flexible spending account is forfeited at the end of a tax yearwhereas the balance in a personal care account may be rolled over fromone plan year to the next.

Subscriber Debit Card

Once a subscriber has coverage under an insurance policy, they may beissued a debit card 201. The debit card may be made from plastic. Thedebit card may comprise raised letters indicating the subscriber's nameand debit card number. The card may further comprise a magnetic strip,electronic chip, or other suitable means into which has been encodedsubscriber identification information. The card may further comprise anarea that the subscriber may sign.

Alternatively, subscribers that only have PCX accounts and no other FSAor conventional HRA accounts may only be issued debit cards when thebalance of their personal care accounts exceeds a certain threshold,such as $10.

Purchasing an Allowed Expense

When a subscriber purchases an allowed expense from an allowed vendor206, the subscriber provides personal debit information 222 to theallowed vendor. The personal debit information may comprise a personalidentifier for the subscriber and a debit card number.

The subscriber may transfer the information to the vendor by providingtheir debit card to the allowed vendor and the allowed vendor may thenswipe the debit card in a debit card reader.

The allowed vendor then transfers allowed expense information 224 to thedebit card processor. The allowed expense information may comprise apersonal identifier of the subscriber, debit card number, the price forthe allowed expense and a merchant identifier code assigned to theallowed vendor.

The merchant identifier code may indicate the type of products orservices that the allowed vendor sells. This can be used by the debitcard processor to determine, at least in part, if the allowed expense isindeed allowed. In this example, allowed means that it conforms to IRSregulations for allowed health care expenses as described above.

The allowed expense may be the cost of a prescription. The allowedvendor may be a pharmacist, such as CVS Corporation.

The allowed expense may alternatively be the copayment due for adoctor's visit.

The allowed expense information may be transferred via a modemconnection or other suitable means.

After the debit card processor receives the allowed expense information,it checks to see if the expense is indeed allowable. As indicated above,a suitable means to determine, at least in part, if an expense isallowable is to compare the merchant identifier code with a list ofallowed merchant identifier codes.

If the expense is indeed allowable, the debit card processor thenexamines the stand-in spending accounts 253, 255 and 257 assigned to thesubscriber to determine if the collective balance in these accounts issufficient to cover the cost of the expense. If it is, then the debitcard processor debits the appropriate spending account(s) by the cost ofthe allowed expense. If it is not, then the debit card processor debitsthe spending accounts by what they have available and records thebalance of what is owed.

The debit card processor then transfers debit card balance owedinformation 226 to the allowed vendor. The debit card balance owedinformation comprises the positive difference between the price of theallowed expense and the collective balance of the spending accountsassigned to the subscriber.

For example, an allowed expense might include the cost of a pair ofglasses. The glasses might cost $300. A subscriber might have $200 intheir stand-in flexible spending account 253 and $150 in their stand-inpersonal care account 257. The debit card processor would first debitthe stand-in flexible spending account by $200 and then debit thestand-in personal care account by $100. The balance of the stand-inflexible spending account would be zero. The balance of the stand-inpersonal care account would be $50. The debit card balance owedinformation would indicate that the subscriber did not owe any money forthe glasses.

Alternatively, for the same glasses, a subscriber might have $100 intheir stand-in flexible spending account and $50 in their stand-inpersonal care account. The debit card processor would first debit thestand-in flexible spending account by $100 and then debit the stand-inpersonal care account by $50. The balance of both spending accountswould be zero. The debit card balance owed information would indicatethat the subscriber owed the allowed vendor $150 for the glasses.

After receiving the balance owed information, the allowed vendor wouldthen convey final debit transaction information 228 to the subscriber.The final debit transaction information might comprise the balance owed.

The final debit transaction information may be transmitted verbally.

The subscriber and the allowed vendor may then conclude the transactionof the purchase of the allowed expense.

The allowed vendor may be an automation, such as a web page, automatedtelephone system or vending machine dispensing prescription drugs.Personal debit information 222 and final debit transaction information228 may be transmitted over the Internet, phone system or othertelecommunications means.

The subscriber may have an agent act on their behalf. The agent may bean automation, such as a computer implemented ordering system.

The subscriber may be a corporate entity, such as an HMO.

Transferring Monetary Credits from an Insurance Company to a Debit CardProcessor

The personal care accounts 256 and other accounts 252, 254, assigned toa subscriber and maintained by the insurance company may be updated bythe debit card processor on a real time basis when a covered expense ispurchased. When a purchase takes place, the debit card processortransmits spending account information 232 to the insurance company.

The spending account information comprises a personal identifier of thesubscriber and the debits or credits to their spending accounts. Theinsurance company subtracts the debits or adds the credits to therespective balances of the personal care accounts and other accountsassigned to the subscriber.

The spending account information may be entered into the insurancecompany's information system automatically.

The transmission of a PCX debit from the debit card processor to theinsurance company can be considered to be a transfer of PCX monetarycredits from the insurance company to the debit card processor. Thus thesystems and methods for electronically transferring government issuedcash from one entity to another would be suitable for transferringPersonal Care Account update information from the debit card processorto the insurance company. The transfer, therefore, may comprise atransmission of a spending account confirmation 234 from the insurancecompany to the debit card processor confirming that the PCX monetarycredits are indeed available for the subscriber.

If the transfer of spending account information 232 and spending accountconfirmation information 234 is not completed in a timely manner, suchas, for example, due to unscheduled downtime in the communications linkcarrying the information, then the debit card manager 204 may makeprovisional adjustments to the appropriate stand-in accounts 253, 255,257 and still transfer debit card balance owed information 226 to theallowed vendor on a real time basis. The provisional adjustments arelater confirmed when the spending account confirmation 234 issubsequently received.

Updating a Subscriber and Employer

The insurance company may periodically transmit account updateinformation 234 to a subscriber. Account update information may comprisethe current balance in the subscriber's personal care account along withany changes to the account and an indication of a reason for eachchange. The information may be transmitted quarterly.

The insurance company may also periodically transmit employee accountbalance information 213 to a given employer 207 on a periodic basis.Employee account balance information may comprise balances, credits anddebits to the traditional HRA and PCX accounts associated with thesubscribers who are employees of the employer. The employer may updatean employee account database 257 based on the employee account balanceinformation.

Actual Payment of Allowed Expenses

Paying a vendor for allowed expenses debited to a subscriber's employersponsored stand-in PCX account 257 may be done in the same manner as istraditionally done for a traditional stand-in HRA account.

On a periodic basis, such as daily, the debit card processor transmitsan authorization for funds transfer 217 to the employer's bank 208. Theauthorization of funds transfer information may comprise anidentification of the employer's bank, an identification of theemployer's account held by the bank, an identification of the vendor'sbank, an identification of the vendor's account held by the vendor'sbank, and an amount of government issued cash or other financialinstrument that is to be transferred from the employer to the vendor.

The employer's bank then transfers 218 funds from the employer's bankaccount 258 to the vendor's bank 209. The vendor's bank then credits thefunds transfer to the vendor's bank account 259. Appropriateconfirmation information 228, 227 is relayed back to the employer's bankand debit card processor.

Thus government issued funds to satisfy debits to a subscriber's PCXaccount are provided directly from an employer to a vendor.

The employer's bank will then provide account balance information 215 tothe employer showing debits to their account 258. The vendor's bank willsimilarly provide vendor account balance information 219 to the allowedvendor showing credits to their account 259.

Substantiation of Allowed Expenses

It may be necessary to substantiate allowed expenses to confirm thatthey are indeed allowed. For example, if the allowed expenses areallowable expenses under Section 213(a) of the Internal Revenue ServiceCode, then it is a legal requirement in the United States that theallowed expenses be substantiated.

Suitable methods for substantiation are described in Rev. Rul. 200343,2003-21 I.R.B. 935 by Barbara Pie, published May 16, 2003, available atwww.irs.gov/pub/irs-drop/rr-0343.pdf (last viewed Jul. 29, 2004), andincorporated herein by reference.

Example

An insurance company offered a new pharmacy benefits plan comprisingallowances for drugs in a given group of drugs. The new pharmacybenefits plan was offered as an alternative to a conventional pharmacybenefits plan requiring copayments for drugs in a given tier of drugs.Both plans were offered to the United States employees of a publiclytraded corporation (the employer). Drugs in the new pharmacy benefitsplan were assigned into 4 different Groups according to theiranticipated impact on subsequent covered medical costs. 18% of theemployees selected the new plan in the first year it was offered. Theseemployees thus became subscribers to the new pharmacy benefits plan.

It was subsequently discovered that the employees of the corporationwished that they could accumulate the unused portions of theirallowances so that the unused portions could be applied to other allowedout-of-pocket medical expenses. Hence in the second year that the newpharmacy benefits plan was offered, provision was made to allowemployees to accumulate unused portions of their allowances and applythe unused portions to other allowed out-of-pocket medical expenses asspecified in the policy. Surprisingly, 40% of the employees now becamesubscribers to the new pharmacy benefits plan.

The provision for accumulating unused portions of the allowancescomprised creating personal care accounts for all employees selectingthe new plan. The personal care accounts were administered as modifiedHealth Reimbursement Arrangements. The personal care accounts wereadministered using Health Reimbursement Arrangement software that hadbeen modified to allow for an initial account balance of zero and thesubsequent accumulation of monetary credits throughout a given planyear. The monetary credits could also be carried over from one plan yearto the next plan year.

Each of the subscribers was provided with a health plan identification(ID) card. Whenever a subscriber purchased a prescription drug, thepharmacy benefits manager adjudicating the purchase set a client limitsavings field contained in a covered expense record associated with thepurchase to the positive difference between the allowance for the drugand the cost of the drug.

The pharmacy benefits manager would then transmit the accumulatedmonetary credits associated with each subscriber to the insurancecompany on a quarterly basis. The insurance company would then updatethe personal care accounts associated with each subscriber. Theinsurance company would then provide each subscriber with an update oftheir personal care accounts indicating the accumulation of the credits.The insurance company also made the personal care account informationfor each subscriber available on the Internet. Each subscriber had toprovide appropriate security information, such as a user ID andpassword, to view their account balance.

The insurance company would provide a debit card to a subscriber whentheir personal care account balance exceeded $10 for the first time.

When a subscriber purchased an allowed health care expense, such as aprescription drug or doctor copayment, they would present their debitcard to the vendor. The vendor would then submit a request for paymentto a debit card processor. The debit card processor would then check tosee if there were enough credits in the subscriber's personal careaccount to cover at least a portion of the allowed health care expense.If there were enough credits, then the debit card manager would indicateto the vendor that no further balance was owed. The debit card vendorwould then direct the employer's bank to debit the employer's bankaccount, transfer funds to the vendor's bank and instruct the vendor'sbank to credit the vendor's bank account with the funds. Thus the vendorwould be paid directly by the employer and the subscriber would not haveto declare the payment as income on their tax return.

The debit card manager would also indicate to the insurance company thatthere was a debit to the subscriber's personal care account.

All transactions were carried out with known security protocolssufficient to reduce the incidence of fraud or error to an appropriatelevel and to comply with all necessary governmental regulationsconcerning patient privacy.

The cost savings to subscribers exceeded expectations. 4,800 subscribersaccumulated $174,000 worth of credits in their personal care accounts in90 days. This indicates that subscribers were actively seeking lowercost but nonetheless effective drugs in order to accumulate credits.

CONCLUSION

One of skill in the art will recognize that insurance is a regulatedindustry. One practicing the methods described and claimed herein willwant to maintain compliance with all applicable local, state and federalregulations, to ensure that the insurance policy is properly presentedto the insured, premiums are properly approved, underwriting properlyoccurs, all necessary regulatory approvals are in place, etc.

While particular embodiments of the present invention have beenillustrated and described, it would be obvious to those skilled in theart that various other changes and modifications can be made withoutdeparting from the spirit and scope of the invention. Any of the aspectsof the present invention found to offer advantages over the state of theart may be used separately or in any suitable combination to achievesome or all of the benefits of the invention disclosed herein.

1. A computerized method for processing a health insurance claim comprising: (a) storing in a first database covered expense data comprising: (1) an identifier for a good or service covered under an insurance policy; and (2) an allowed amount for said good or service equal to a maximum amount to be paid under said insurance policy for said good or service; (b) storing in a second database personal care account data comprising for each subscriber of said insurance policy: (1) a subscriber identifier; and (2) a personal care account associated with said subscriber identifier; (c) receiving at a server claim data for a covered expense for a subscriber of said insurance policy, said claim data comprising: (1) a subscriber identifier; (2) an identifier for a good or service; and (3) an actual cost for said covered expense; (d) retrieving at said server from said first database an allowed amount for said covered expense; (e) calculating at said server a monetary credit for said covered expense equal to the difference between said allowed amount and said actual cost; (f) if said monetary credit is positive, adding said monetary credit to a balance of a personal care account associated with said subscriber identifier at said second database.
 2. The computerized method of claim 1 wherein said covered expense is selected from the group consisting of prescription drugs and medical services.
 3. The computerized method of claim 2 wherein said covered expense is selected from a group of prescription drugs with different therapeutic indications.
 4. The computerized method of claim 2 wherein said covered expense is selected from a group of prescription drugs with similar therapeutic indications.
 5. The computerized method of claim 2 wherein said prescription drugs are organized into at least two groups according to anticipated impact on subsequent medical costs.
 6. The computerized method of claim 2 wherein said allowed amount relates to an anticipated impact of said covered expense on subsequent health care costs that said subscriber is likely to incur if said subscriber did not have said covered expense.
 7. The computerized method of claim 1 further comprising: (g) storing in a third database allowed expense data comprising identifiers for goods or services payable from said personal care account; (h) receiving at said server claim data for an allowed expense for a subscriber of said insurance policy, said claim data comprising: (1) a subscriber identifier; (2) an identifier for an allowed expense; (3) an actual cost for said allowed expense; and (i) deducting from said personal case account for said subscriber monetary credits equal to said actual cost for said allowed expense.
 8. A computerized system for processing a health insurance claim comprising: (a) a first database storing covered expense data comprising: (1) an identifier for a good or service covered under an insurance policy; (2) an allowed amount for said good or service equal to a maximum amount to be paid under said insurance policy for said good or service; (b) a second database storing personal care account data comprising for each subscriber of said insurance policy: (1) a subscriber identifier; (2) a personal care account associated with said subscriber identifier; (c) a server that executes instructions to (1) receive at said server claim data for a covered expense for a subscriber of said insurance policy, said claim data comprising: (A) a subscriber identifier; (B) an identifier for a good or service; and (C) an actual cost for said covered expense; (2) retrieves at said server from said first database an allowed amount for said covered expense; (3) calculate at said server a monetary credit for said covered expense equal to the difference between said allowed amount and said actual cost; (4) if said monetary credit is positive, add said monetary credit to a balance of a personal care account associated with said subscriber identifier at said second database.
 9. The computerized system of claim 8 wherein said covered expense is selected from the group consisting of prescription drugs and medical services.
 10. The computerized system of claim 9 wherein said covered expense is selected from a group of prescription drugs with different therapeutic indications.
 11. The computerized system of claim 9 wherein said covered expense is selected from a group of prescription drugs with similar therapeutic indications.
 12. The computerized system of claim 9 wherein said prescription drugs are organized into at least two groups according to impact on subsequent medical costs.
 13. The computerized system of claim 9 wherein said allowed amount relates to an anticipated impact of said covered expense on subsequent health care costs that said subscriber is likely to incur if said subscriber did not have said covered expense.
 14. The computerized system of claim 8 further comprising: (g) a third database storing allowed expense data comprising identifiers for goods or services payable from said personal care account; (h) instructions executing at said server to: (1) receive at said server claim data for an allowed expense for a subscriber of said insurance policy, said claim data comprising: (A) a subscriber identifier; (B) an identifier for an allowed expense; (C) an actual cost for said allowed expense; and (2) deduct from said personal case account for said subscriber monetary credits equal to said actual cost for said allowed expense.
 15. A computerized method for processing a health insurance claim comprising: (a) storing in a first database covered expense data comprising: (1) an identifier for a good or service covered under an insurance policy; and (2) an allowed amount for said good or service equal to a maximum amount to be paid under said insurance policy for said good or service; (b) storing in a second database personal care account data comprising for each subscriber of said insurance policy: (1) a subscriber identifier; (2) a personal care account associated with said subscriber identifier; and (3) a balance equal to monetary credits received for purchases of covered expenses at costs below allowed amounts for said expenses; (c) receiving at a server claim data for a covered expense for a subscriber of said insurance policy, said claim data comprising: (1) a subscriber identifier; (2) an identifier for a good or service; and (3) an actual cost for said covered expense; (d) retrieving at said server from said first database an allowed amount for said covered expense; (e) calculating at said server a monetary credit for said covered expense equal to the difference between said allowed amount and said actual cost; (f) if said monetary credit is negative, applying to said claim a monetary credit from a personal care account associated with said subscriber identifier at said second database.
 16. The computerized method of claim 15 wherein said covered expense is selected from the group consisting of prescription drugs and medical services.
 17. The computerized method of claim 16 wherein said covered expense is selected from a group of prescription drugs with different therapeutic indications.
 18. The computerized method of claim 16 wherein said covered expense is selected from a group of prescription drugs with similar therapeutic indications.
 19. The computerized method of claim 16 wherein said prescription drugs are organized into at least two groups according to anticipated impact on subsequent medical costs.
 20. The computerized method of claim 16 wherein said allowed amount relates to an anticipated impact of said covered expense on subsequent health care costs that said subscriber is likely to incur if said subscriber did not have said covered expense. 